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An accountable care organization (ACO) in Vermont is waiving the three-day stay rule for skilled nursing facility use, while the Next Generation ACO model will cover some home visits.

August 24, 2018 - Ensuring patients receive the right post-acute care at the right time is key to controlling costs in accountable care organizations (ACOs) and other population-based alternative payment models. With this in mind, Vermont’s statewide ACO program is now allowing two local hospitals to release their patients to specific skilled nursing facilities after a short hospital stay.

OneCare Vermont recently announced that two of its participating hospitals can discharge patients to skilled nursing facilities after just one day, the ACO announced in an emailed press release. Skilled nursing facilities must have a minimum three-star rating to qualify for the waiver.

Medicare requires hospitals to keep patients in a bed for at least three consecutive days before releasing them to a skilled nursing facility. Failing to wait a full three days prior to discharge will result in Medicare not covering the skilled nursing facility visit.

However, OneCare developed the post-acute care waiver to ensure patients attributed to the ACO can receive high-quality skilled nursing facility care under the right circumstances.

“Under the waiver program, patients can access skilled care without making the difficult decision to pay a high out-of-pocket fee or be discharged home without the needed support to effectively and efficiently rehabilitate,” stated Norman Ward, MD, Chief Medical Officer of OneCare Vermont.

“We’ve all been waiting for this and we are thrilled to be implementing this program with our community partners to improve care for patients. It offers the right patient the right care at the right time in the right place,” he added.

The Next Generation ACO that also works with Vermont’s Medicaid program, private payers, and self-funding insurance programs formed in January 2018. The ACO intends to lower healthcare costs while improving care quality and health outcomes for the 112,000 Vermonters covered by the organization.

As part of their mission to improve care value, OneCare relaxed post-acute care requirements to reduce the number of unnecessary hospital stays and emergency department visits after an acute episode. The ACO also intends for the waiver to decrease hospital-acquired infections.

Potentially preventable readmissions, emergency department visits, and hospital-acquired infections can run up a patient’s bill.

Hospitals spend $41.3 billion on patients readmitted to the hospital within 30 days of discharge, according to the Agency for Healthcare Research and Quality (AHRQ). And the agency estimates hospital-acquired conditions added $600 to $48,000 in additional costs per case, while excess mortality ranged from five deaths per 1,000 cases to 150 deaths per 1,000 cases.

The added costs and care quality reduction from expensive, adverse events can jeopardize an ACO’s goal of reducing costs and improving patient outcomes. Therefore, giving patients the highest quality post-acute care is key to ensuring costly, adverse events do not occur shortly after a hospital stay.

OneCare intends to decrease the chances of patients experiencing a costly readmission or emergency department visits through the skilled nursing facility waiver.

But a national ACO program is taking a different approach with its post-acute care rules. CMS recently announced to Medicare payment contractors that the Next Generation ACO model will cover certain care management home visits in 2019.

Starting in January, Medicare will cover up to two care management visits at a patient’s home within 90 days of patients seeing a provider in a Next Generation ACO. The new benefit enhancement will cover items and services that would traditionally be covered under Medicare Part B and are furnished “incident to” professional physician or practitioner services.

The benefit enhancement will also waive the direct supervision requirement, allowing auxiliary personnel to furnish services or supplies under the billing physician’s or practitioner’s general supervision.

CMS intends for the added Next Generation ACO benefit to help organizations control costs and prevent costly healthcare events, like a hospitalization.

“Building upon the Next Generation ACOs’ experience in offering the Post-Discharge Home Visits benefit enhancement, the model will offer a new Care Management Home Visits benefit enhancement to equip the Next Generation ACOs with a new tool to provide home visits proactively and in advance of a potential hospitalization,” the federal agency wrote.

Delivering high-quality care at a patient’s home can significantly reduce healthcare costs while improving care quality.

MedStar Health in Maryland reported in 2017 that home-based primary care for high-risk patients reduced Medicare costs from an average of almost $51,000 per patient to $44,455 in two years. At the same time, hospital costs dropped about $3,000 per patient.

The health system’s Director of Geriatrics and house call program founder K. Eric De Jonge, MD, attributed the cost reduction to catching potentially adverse events before they happened.

“The reason for doing house calls is to really focus on the patients who have to call 911 and they land in the emergency room,” he said. “The program is there to really prevent 911 phone calls, prevent unnecessary hospital stays, and help patients stay at home for the rest of their life.”

For ACOs, controlling a patient’s outcomes and healthcare costs beyond the hospital’s walls is vital to effectively managing a patient’s health. Ensuring post-acute care is delivered at the right time, in the right place, and at the right cost is crucial to earning shared savings payment and enhancing care quality.

Relaxing traditional post-acute care rules may be the key to helping ACOs extend their reach beyond the hospital or doctor’s office to influence positive health outcomes.